Hypothesis: The primary major leg amputation rate of diabetic patients that present with a foot ulcer in an emergency room is 22.5%. Over 1/3 of these are above knee amputations (AKA). We hypothesized that a multidisciplinary approach to limb salvage would have a significantly lower primary major leg amputation rate. In addition, we theorized that the amputation could be limited to the highly functional below-knee amputation (BKA) and avoid the AKA.

Conclusion: The diabetic’s risk of primary amputation decreased tenfold due to being initially evaluated in a clinic specializing in limb salvage. No AKAs were necessary. A multi-disciplinary team therefore can significantly reduce the major leg amputation rate in diabetic patients. Because of the success of the posterior flap design for BKA, AKA should be required only in the rarest of circumstances.

Summary of Methods/Results: We reviewed the Georgetown Limb Salvage registry to identify all diabetic ambulatory patients from 1990-1999 who underwent primary major leg amputations. Twenty five out of 937 diabetic patients who presented with ulcer/gangrene underwent primary amputation (2.7%). All patients prior to amputation were evaluated by the plastic surgeon, orthopedic and the vascular surgeon on the limb salvage team. Peripheral vascular disease was present in 20/25 (80%), and 60% of those patients had undergone previous revascularization attempts while 40% were deemed non-revascularizable. Forty percent of these patients suffered from renal failure. The wound presentations included: frank gangrene/osteomyelitis (90%), trauma (5%), ulcer (2%) and unknown (3%). All patients had involvement of the hindfoot including: calcaneus, talus, and or ankle joint. An initial aggressive debridement was performed to realistically assess chances for salvage. If it was deemed impossible to salvage a biomechanically sound foot, a primary amputation was performed. Reasons for non-salvageability included: a non-reconstructable soft tissue defect and/or excessive bone destruction in the hindfoot. All BKAs were performed using a posterior flap design based on the sural artery circulation. Successful amputations were realized in all patients and no patient required a further AKA. Complications of the BKA occurred in 28% of patients: dehiscence (17%), partial flap loss (5%), hematoma (2%), and cellulitis (1%). Long-term follow up (average of 4.5 years) was available 19 patients. Seventy percent of these patients were still alive.